Differentials
Spinal epidural abscess
SIGNS / SYMPTOMS
Fever is often present.
Potential risk factors include a history of intravenous drug use, diabetes mellitus, history of recent spinal surgery or trauma, indwelling spinal catheter, contiguous local infection, concomitant bacteraemia or endocarditis, chronic renal disease, and immunosuppression (e.g., HIV infection, malignancy).
INVESTIGATIONS
Gadolinium-enhanced MRI spine shows epidural space and bone involvement of abscess.
Blood or cerebrospinal fluid culture will be positive for causative organism - most commonly Staphylococcus aureus, although many other bacteria have been implicated. FBC, CRP, and ESR are usually elevated.
Malignant spinal cord compression (MSCC)
SIGNS / SYMPTOMS
Pre-existing cancer diagnosis and/or systemic signs of malignant disease (e.g., unexplained weight loss).[23]
Prostate, lung, breast, renal, and thyroid cancers have been particularly associated with MSCC, but any systemic cancer can metastasise to the spine.[41]
INVESTIGATIONS
MRI shows spinal neoplasm.
Multiple sclerosis
SIGNS / SYMPTOMS
Common symptoms include visual disturbance in one eye (e.g., greying or blurring); fatigue; poor balance.
INVESTIGATIONS
MRI typically shows demyelinating lesions in the spinal cord.
Brain MRI typically shows demyelination perpendicular to the lateral ventricles and corpus callosum.
Cerebrospinal fluid analysis may show oligoclonal bands.
Transverse myelitis
SIGNS / SYMPTOMS
Various aetiologies, including post-infectious, autoimmune, and inflammatory.
More than half of patients have a systemic viral illness 1-4 weeks before onset of neurological symptoms. Most have leg weakness of varying degrees of severity. The arms are involved in a minority of cases.
INVESTIGATIONS
MRI shows focal demyelination with possible enhancement at the appropriate level, and excludes compressive lesion.
Cerebrospinal fluid analysis shows pleocytosis with a modest number of lymphocytes and increase in total protein.
Degenerative myelopathy (cervical/thoracic)
SIGNS / SYMPTOMS
Presents with progressive neurological symptoms, often including loss of balance and upper body symptoms (e.g., loss of hand or digit dexterity; loss of fine motor control); brisk reflexes (as opposed to diminished or absent reflexes, which may be seen in CES). May have upper limb radicular pain.[42][43]
INVESTIGATIONS
MRI shows cervical or thoracic stenosis with or without cord signal change. Confirmation of the diagnosis requires both typical clinical features and positive radiological findings.
Traumatic conus medullaris (CMS)
SIGNS / SYMPTOMS
Patients with axial compression injury (e.g., fall, motor vehicle accident) or flexion injury can experience a vertebral body fracture with retropulsion of a fragment of bone or disc, and spinal shock. This usually resolves in a few days. Penetrating injuries (e.g., projectile, knife) often cause loss of function and, with entry forces, conus medullaris syndrome or CES-like symptoms.
INVESTIGATIONS
A history of the injury and some description of the force vectors (if known) leads to the diagnosis. Imaging includes MRI without contrast and/or CT scanning. CMS may result from injury of vertebrae T12 to L2, and involves damage to neural structures from spinal cord segment T12 to nerve root S5; CES may result from an injury of vertebrae L3 to L5, and involves damage to nerve roots L3 to S5.[44]
Benign prostatic hypertrophy
SIGNS / SYMPTOMS
Urinary symptoms not accompanied by any change in sensation.
Absence of sciatica or back pain.
Digital rectal examination may detect an enlarged prostate.
Generally presents in older men (age >50 years).
INVESTIGATIONS
No findings on spinal MRI.
Typically a clinical diagnosis with negative urinalysis.
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